We asked 90 C-suite executives about their biggest concerns. Here's what they told us.

At the start of every year, the Health Care Advisory Board research team conducts the Advisory Board Research Annual Health Care CEO Survey to identify the top strategic priorities for hospital and health system leaders. We were especially curious how executives plan to focus their agenda in 2019 after watching political uncertainties wax and wane and the private sector take over as the top catalyst for industry transformation in 2018.

In this year's survey, we asked respondents to rate 29 issues on a scale of "A" to "F," with "A" indicating the greatest interest in learning more from Advisory Board researchers about the topic. The top-ranked areas for the 90 hospital and health system C-suite executives who responded to our 2019 survey were:

Redesigning health system services for population health (51.9% ranked "A"); and

Innovative approaches to expense reduction (51.3% ranked "A").

After reviewing the detailed results from this year's survey, we observed four key takeaways driving hospitals' and health systems' C-suite agenda right now:

1. Margin pressures are not relenting, but executives' top priority has shifted from cost control to revenue growth.

For the past two years, C-suite executives have consistently rated margin management as their top strategic priority. This focus reflects the dire financial reality facing many hospitals and health systems today. In 2017, median operating margins among nonprofit hospitals hit an all-time low of 1.6%, after operating expense growth outpaced operating revenue growth for two consecutive years.

Moody's U.S. nonprofit hospital preliminary medians for fiscal year 2018 suggest that health systems are starting to show signs of financial stability, with operating margins holding steady as the growth of revenues and expenses converged last year. However, margins remain razor thin due to sustained downward pressure on revenue growth and declining patient volumes, especially as more patients receive care in the outpatient setting. While cost containment remains a major strategic priority, executives have shifted more of their focus to strategies designed to bolster revenue growth moving forward.

2. Executives are looking beyond the hospital to capture new revenue growth.

In contrast to previous periods of margin pressure, structural shifts within the industry—rather than temporary declines in the overall economy—are driving today's revenue challenges. As a result, hospitals and health systems are seeking new strategies for capturing revenue growth. "Increasing ambulatory access" and "strengthening primary care alignment" were among the highest-scoring topics on this year's survey; both topics also experienced a notable increase in interest relative to 2018. Interest in growing the outpatient procedural book of business remained steady. Overall, executives remain hyper-focused on ambulatory growth, with a particular interest in moving upstream and capturing revenue from access and primary-care focused strategies.

Different types of organizations are embracing different strategies for growing revenue. While all respondents expressed strong interest in improving ambulatory access, leaders from larger health system also indicate intentions to explore diversified revenue streams.

3. Physicians will be critical to margin management efforts across the board.

In 2018, when executives were laser-focused on cost control, executives' interest in physician-related topics dropped. This year, however, leaders are highlighting physicians' integral role in both revenue growth and cost control, and physician-related issues returned as a leading priority. Physician-related topics scored even higher among CEOs than other C-suite respondents, indicating a strong likelihood that hospitals and health systems will place more time and effort on physician partnership to advance margin goals. However, strengthening ties with physicians could be increasingly difficult for hospitals and health systems. Private equity firms, health plans, retailers, and technology companies are all vying with hospitals and health systems for physician talent and are fueling unprecedented competition in the market for physician partners.

4. Innovation is becoming a key response to industry disruption.

In addition to the C-suite, our survey also polls broader hospital and health system administrators. This year, the highest-ranked topic across all respondent groups was "hardwiring innovation into planning, improvement, and staff culture," with 51% of the 330 respondents ranking it an "A." This same topic was ranked number eight on the list in 2018.

The rising interest in innovation demonstrates hospitals' and health systems' reaction to intensifying financial pressures and competition from new entrants to the health care market—especially Silicon Valley, big tech companies, and private equity firms—and the need to evolve quickly in an industry facing disruption.

How your organization can sustainably control costs and grow revenue

In many ways, hospitals and health systems are comparable to stars. Take, for example, Antares, a red supergiant that shines brightly from far away, but faces a significant problem upon closer inspection: it is nearing the end of its life. It is rapidly devouring all its fuel to burn so brightly and will eventually collapse. Similar to Antares, many hospitals and health systems appear healthy from afar. But with their operating expenses now outpacing their operating revenue, they may be headed downhill.

Antares Health System, Advisory Board’s financial model of an average health system, illustrates the magnitude of this challenge. Absent intervention, Antares will have a –4.2% operating margin in 2025. Use this infographic to learn how Antares Health System (and your organization) can reverse course to ensure a bright and sustainable future.